HomeMy WebLinkAboutApp-Permit-ComplianceNo. 160"V-1�?-3 1 vV owl w � ' ' ' I FEE J S -i (90
/ 7� �' C®MMO LTH OF MASSAC14USETTS C, =s05c
Board of Health, )(Ag 7 yr* , MA.
APPLICATION FOR DISPOSAL SYSTEM CONSTRUCTI®N PERMIT
Application for a Permit to Construct( ) Repair (V�Upgrade ( ) Abandon( ) - ❑ Complete System ❑ Individual Components
Location 3 y Loo "„ -T
a
Owner's Name )<e -\J; e\ oz -n
Map/Parcel#
Address LbOK q- . a,r~r/1, &c,—t
Lot#
Telephone# 2j (o . yt7 y0 7 f
Installer's Name �o 67- B, our to
Designer's Name
Address ZN 6 retUyk-rn PJ
Address
Telephone#$� � j pq- V p58
Telephone#
Type of Building ►-C�
Dwelling - No. of Bedrooms
Other - Type of Building
e., rta I
No. of persons
Lot Size
sq. ft.
_ Garbage grinder ( )
Showers ( ), Cafeteria ( )
Other Fixtures
Design Flow (min. required) gpd Calculated design flow Design flow provided gpd
Plan: Date Number of sheets Revision Date
Title
Description of Soil(s)
Soil Evaluator Form No.
Name of Soil Evaluator
Date of Evaluation
DESCRIPTION OF REPAIRS OR ALTERATIONS &2 (ay q f � O r� e " P f ode. r1no,"I 14v -v :5e- 7m
The undersigned agrees to install the above described Individual Sewage Disposal System in accordance with the provisions of TITLE 5 and
further agr1ees ton t to lace the system in operation until a Certificate of Compliance has been issued by the Board of Health.
Signed w l tib, 13c ,9Uf-ifs.,Zr)G Date y" 19' 1
V
Inspections
No. i Q o w- --2-9513 FEE
COMMONWEALTH OF MASSACHUSETTS �A— o o 5�
ry Board of Health, YA-9-MOSM" MA.
CERTIFICATE OF COMPLIANCE 16V
Description of Work: Individual Component(s) ❑ Complete System
The undersigned hereby certify that the Sewage Disposal System; Constructed ( ), Repaired r ). Upgraded ( ), Abandoned ( )
by: 46er"f - ottN r dt L
at .3 LI L 00 r,v v T - -
has been installe4 in ac c rdance with the ro�isions of310CMR 15.00 (Title 5) and th approved design plans/as btuilt plans relating to
application No. dated 2Z f ! . Approved Design Flow and
Installer i' r }t" (fJ, S�,C•"` y -Y
? _ .";?
Designer: Inspector: t`E,!- Date:"' ! /
The issuance of this permit shall not be construed as a guaradiee that the system will function as designed.
l': Ci,W-1 (Q. . 000(.x. l:(f ��r'1�.),r,�;Gll(1.i��<,[.Ut: l..�::. C��.. .: iJ ..,_v.. ..__ _.._ .,<:"OUCG,..C'011^CC
No. dN-QC -17�-` 9:58 ti° . `' . 00r,- CO . FEE � S5. 00
COMMONWEALTH Of MASSACHUSETTS
Board of Health, i NP-MQQT4 , MA.
DISPOSAL SYSTEM CONSTRUCTION PERMIT
Permission is hereby grantedto; Construct( ) Repair( Upgrade( ) Abandon( ) an individual sewage disposal system
at 3 � Loo P -w -r ky . l + Ias described in the application for
Disposal System Construction Permit No. �/ , dated 4-:41 '//7
6 too
Provided: Construction shall be completed within A;I-Fee-- ears of the date of this perm LtAll local conditions must be met.
Form 1255 Rev. 5/96 A.M. Sulkin Co. Chadestown.MA Date -1 ; -/ Board of Health
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